水气上冲证治

一、水气的概念（此处水气非指水肿）古人对水气的概念，有认为水气是水之寒气，如成无已注水气上冲：“水寒相搏，肺寒气逆”；也有人认为水气即是水饮，如钱天来注“水气、水饮之属也。”我认为他们似乎各自说对一半，因水与寒，往往统一发病，水指其形，寒则指其气，如影之随形，不能分离。所以水气的概念，既有水饮，也有寒气。

Water Qi upward surging patterns and treatment 

1. Concept of Water Qi (here, water qi does not refer to edema). In ancient times, there were various concepts regarding water qi. Some believed that water qi was the cold qi of water, such as in the saying by Cheng Wuji in relation to the upward surging of water qi “when water and cold clash, cold in the lung [will result in] counterflow qi.” Others believed that water qi was simply water-rheum, as mentioned by Qian Tianlai: “Water qi belongs to water-rheum.” I believe they each seem to be partially correct because water and cold often jointly cause illnesses. Water represents its form, while cold indicates its qi, like a shadow following its form, inseparable. Therefore, the concept of water qi includes both water-rheum and cold qi.

二、水气上冲的证机

水气上冲证，为临床常见病和多发病。历代医家比较重视，在治疗方面也有所发展。此证源出《伤寒论》及《金匮要略方论》，仲景提出以苓桂为主方的相应治疗，为后世治疗水气上冲创立了证治基础。但原文中的苓桂方证，加减化裁，有机地分列于不同的篇章，使人难以掌握全面。而无法引用。为此，进行综合归纳，提要钩玄并参以已意，务使水气上冲体系与系列方证特点而大白于医林。

2. Patterns and Mechanisms of the Upward Surging of Water Qi

The upward surging of water qi is a common and frequently occurring clinical condition. Physicians of various generations have attached great importance to it and have also made developments in its treatment. This condition originated from the “Shang Han Lun” and the “Jin Gui Yao Lue Fang Lun.” Zhongjing proposed the corresponding treatment mainly using the formula Linggui [Zhugan Tang], establishing the basis for the treatment of the upward surging of water qi in later generations. However, the original Linggui formula and its patterns, modifications, and variations are scattered throughout different chapters, making it difficult for people to grasp comprehensively and impossible to reference. To this end, a comprehensive summary is conducted, highlighting the essential points and incorporating personal insights, with the aim of making the characteristics of the upward surging of water qi and the related formula presentations clear to the medical community.

《伤寒论》第67条内容，是论水气上冲证治，我认为这一条是论“水心病”的代表作。

“水心病”的病名，是受西医“风心病”病名影响而产生的，病名突出了病证的重点，反映了病的实质问题，比“水气凌心”的名称直截了当，一见便知。

关于这一条的原文是“伤寒若吐若下后，心下逆满、气上冲胸，起则头眩，脉沉紧、发汗则动经，身为振振摇者，茯苓桂枝白术甘草汤主之。”文中的“若吐若下”，先点出了证机属虚而非实。正是心阳先虚，然后才有“水心病”的发生。

Line 67 of the Shang Han Lun discusses the treatment of the upward surging of water qi. I believe this section represents the concept of “water heart disease.”

The term “water heart disease” influenced the name “rheumatic heart disease” in Western medicine. The name highlights the focus of the disease, reflecting its essential problem, which is more direct than the name “water qi encroaching on the heart.”

The line in the original text says: 

“In cold damage [disease] following vomiting or purgation, [if there is] counterflow fullness below the heart, qi surging upward into the chest, dizziness upon rising, and a deep and tight pulse; If sweating is promoted this will stir the channels and there will be quivering and trembling, and Fuling Guizhi Baizhu Gancao Tang governs.” 

The phrase “[following] vomiting or purgation” indicates that the mechanism of the condition is related to deficiency rather than excess. It is precisely the deficiency of heart yang that leads to the occurrence of “water heart disease.”

心脏属火，为阳中之太阳。上居于胸，秉火阳之权威，震慑下焦水寒之邪不敢越雷池一步。今因“吐下之余定无完气”，心阳一虚，则坐镇水寒之权威失势，因此在下焦的水寒阴气便有可乘之机，乃有“水心病”发生。

The heart belongs to fire and is the Taiyang within the Yang. It resides in the chest, holding the authority of fire Yang, intimidating the evil of water cold in the lower jiao, not daring to step beyond the threshold of the Lei Chi [or beyond its limits]. Now, due to “the deficiency of Qi after vomiting or diarrhea,” when the heart Yang is deficient, the authority of restraining water cold in the lower jiao is lost. Therefore, there is an opportunity for the cold and Yin Qi in the lower jiao to take advantage, leading to the occurrence of “water heart disease.”

近世医者，受西医学之影响，只知“心主血脉”，“诸脉系于心”所发生的心血管瘀阻的心绞痛和冠心病。反而不知心的生理特点在于阳气。《素问•六节脏象论》说：“心者，生之本，神之变也。…为阳中之太阳，通于夏气.” 这段话是说心为生命的根本，主宰神明的变化。心有这大的功能，乃是它的阳气功能所决定。因为心属火脏，而上居于胸，胸与火皆属阳，故心称为“阳中之太阳”。心主阳气为第一位、心主血脉为第二位。心主血脉、心主神志，都与心阳的主导作用有关。如果心阳亡失，则就停止了搏动，血脉不行、神志消灭。

In modern times, influenced by Western medicine, many physicians only recognize that “the heart governs the blood vessels” and the occurrence of angina pectoris and coronary heart disease due to blood stasis in the heart where “all vessels converge.” However, they fail to recognize the physiological characteristics of the heart lying in its Yang Qi. The Suwen • Discussion on the Six Sections on the Organs” states: “The heart is the root of life, [it is responsible] for the changes of the spirit… It is the Taiyang within the Yang, connected with the Qi of summer.” This passage means that the heart is the foundation of life, governing the changes of the spirit. The heart’s extraordinary function is determined by its Yang Qi function. As the heart belongs to the fire organ and resides in the chest, both the chest and fire belong to Yang. Therefore, the heart is referred to as the “Taiyang within Yang.” The heart primarily governs Yang Qi, followed by governing the blood vessels. Both governing the blood vessels and the spirit are related to the dominant role of heart Yang. If heart Yang is lost, pulsation stops, blood circulation ceases, and consciousness disappears.

“水心病”以心阳虚为主，诱发水寒之邪从下而上冲打击心胸阳气、血脉的流通。同时也应该看到在“水心病”的同时，必然中焦的防水大坝的脾土，和下焦管理水气的肾阳也表现了松弛无力，不能制伏水寒之邪上行亦大有关系。“心下逆满”的“逆”之一字，义有双关，既指水气上逆之病机，而又道出相应之症状。“满”，就是胀满，或叫痞满，为上腹部的气机痞塞不通所致，因而出现胀满不通之证。

“Water heart disease” primarily manifests as deficiency of heart Yang, which triggers the invasion of water-cold pathogens from below, attacking the circulation of heart-chest Yang Qi and the blood vessels. At the same time, it should be noted that in ‘water heart disease,’ the spleen’s earth element, which acts as a dam against water in the middle burner, and kidney yang, which governs the water Qi in the lower burner, also show signs of laxity, failing to contain the upward movement of pathogenic cold-water. The term “逆” (nì), meaning “reversal” or “counterflow,” in “counterflow fullness below the heart” carries a dual implication. It not only indicates the pathological mechanism of water Qi rising in reverse but also conveys corresponding symptoms. “Fullness” refers to distension or fullness, also known as “glomus fullness,” caused by the blockage of the Qi mechanism and lack of free flow in the upper abdomen, resulting in distension and fullness.

“心下逆满”，旧注解为“胃脘之间”证候。殊不知此乃心脏阳虚见证之一，上虚而气不降所以为中满也。凡心脏病之心下痛与痞满，而误诊为胃脘病者，临床所见较多，医者所不可不察也。

“Counterflow fullness below the heart,” traditionally interpreted as a symptom between the epigastrium and the stomach, is actually one of the manifestations of heart Yang deficiency. It occurs because of the deficiency of Yang Qi ascending, resulting in fullness in the middle. It’s common in clinical practice to mistake heart-related pain and fullness below the heart as gastric epigastric disorders, which physicians must be vigilant about.

今考心阳虚于上，水寒之气动于中，故有“气上冲胸” 直犯离宫之变，仲景不言气冲于胸之具体见证，今特补述于下：胸为心之宫城，乃阳气所会之地。高学山所谓“光芒四射中，但觉一团太和之元气相聚耳”。今心阳被水寒之邪所過，则自觉胸中满闷，或兼见憋气与疼痛。肺居胸中，行使冷节之令，水寒凌肺，金寒津凝，则可出现咳嗽，气喘，痰这较乡，面部虚浮等证。

Now, considering the deficiency of heart Yang above and the movement of water-cold Qi in the middle, hence the manifestation of “qi rushing upwards to the chest,” directly affecting the palace of separation. Zhang Zhongjing did not specifically mention the manifestations of Qi rushing to the chest, so I’ll elaborate: the chest is where the heart’s Qi congregates, a place of harmony. As Gao Xueshan said, “Rays of light radiate from the center, sensing only a gathering of the great harmonizing source qi.” If heart Yang is invaded by water-cold, the patient may feel fullness and stuffiness in the chest, accompanied by breathlessness and pain. As the lungs reside in the chest, governing the command of cold, when water-cold intrudes upon the lungs, causing the condensation of cold fluids, symptoms such as coughing, wheezing, thick phlegm, facial edema, and so on may appear.

“起则头眩”，是指病人头晕为重，只能静卧，不敢起动。造成眩晕原因有二：一是心脾阳虚，清阳之气不足上养清窍：一是水气上冲，阴来搏阳，清阳既虚且抑所以头眩。

“Dizziness upon rising” refers to severe dizziness upon standing, leading the patient to remain lying down out of fear of exacerbating the dizziness. There are two causes of dizziness: first, heart-spleen Yang deficiency, where insufficient clear Yang Qi ascends to nourish the head; second, the upward rush of water Qi, Yin battling against Yang, resulting in both deficiency and suppression of clear Yang, thus causing dizziness.

我们结合临床观察，水气上冲头目尚不止此，每见视力下降，目见黑花，耳聋、鼻塞与不闻香臭等五官科疾患。

Based on clinical observations, the manifestations of water Qi rushing upward are not limited to those mentioned above. It is often associated with disorders of the five sensory organs, including decreased vision, seeing black spots, hearing loss, nasal congestion, and loss of sense of smell.

徐水县农民，李某某，56岁，患鼻塞证，尤以夜晚为甚，只能以口代鼻呼吸，所以口腔干涸为甚。偶因“心悸”倩余为治。辨为水气凌心之证，于苓桂术甘汤五贴。服讫而鼻塞随之痊愈。

昌黎中学，李某年已不惑，患视网膜炎，视物右上方有黑色物体遮盖不散。曾服益气聪明汤，杞菊地黄汤等方，无效可言。余见其面黧舌水、脉弦而叉心悸头晕，辨为水气上冲、蒙蔽清阳之证。为疏苓桂术甘汤加泽泻。约服三十余剂，而眼前之黑花消失不见。

Mr. Li, a 56-year-old farmer from Xushui County, suffered from nasal congestion, particularly severe at night, forcing him to breathe through his mouth, resulting in severe dryness of the mouth. Occasionally experiencing palpitations, he sought treatment. Diagnosed with the syndrome of water Qi encroaching on the heart, he was treated with the formula Linggui Zhugan Tang. After taking [the formula], his nasal congestion completely recovered.

Mr. Li, a senior student at Changli High School, in his fourties, suffered from retinitis, with a dark object obstructing his upper right field of vision. He had previously tried various prescriptions such as Yiqi Congming Tang and Qiju Dihuang Tang, with little effect. Upon examination, his complexion was sallow, tongue was pale and swollen, and his pulse was wiry and irregular, [and he also experienced] palpitations and dizziness. Diagnosed with the pattern of water Qi rushing upward and obstructing clear Yang, he was prescribed Linggui Zhugan Tang with added Ze Xie. After approximately thirty doses, the dark spots in his vision disappeared.

根据临床观察，水气上冲还往往出现咽喉不利，类似“梅核气”证，梗塞喉中，吐之不出，咽之不下。

文革前余带学生在城子矿实习。某生治一白姓妇女，患梅核气，经用《金匮》半夏厚朴汤，已三进而丝毫无效，乃转余诊。切其脉弦，视其舌苔则水滑欲滴。余辨为水气上冲，咽喉被水寒所痹塞而非痰气之证。乃用桂枝12克，茯苓30克，白术10克，炙甘草6克，连服五剂，咽喉通利，病已愈矣。某生讶以为神，间曰：半夏厚朴汤方为何无效？

曰：半夏厚朴汤治痰气上凝之喉痹；苓桂术甘汤则治水气上冲之喉痹。此证脉弦、舌水而是其候，误为痰气遂有“差之毫厘，谬之千里”，某生叹服。

“脉沉紧”，沉主里，又主水病，弦紧为寒，沉紧正是水寒为病的反映。

Based on clinical observations, water Qi rushing upward often manifests as discomfort in the throat, resembling the pattern of “plum pit qi,” where there is a sensation of obstruction in the throat, as if something is stuck and cannot be swallowed or expelled.

Before the Cultural Revolution, I took students to intern at the Chengzi Mine. One student treated a woman surnamed Bai who had plum pit qi. She had undergone three courses of treatment with Banxia Houpo Tang from the “Jingui Yaolue” but showed no improvement, so she was referred to me for diagnosis. Upon palpating her pulse, it was wiry, and upon observing her tongue coating, it appeared moist and slippery. I diagnosed her with water Qi rushing upward, causing obstruction in the throat due to water-cold, rather than phlegm obstruction. I prescribed Guizhi 12g, Fuling 30g, Baizhu 10g, and Zhi Gancao 6g to be taken continuously for five doses. Afterward, her throat was clear and the condition was resolved. The student was amazed and asked, “Why was Banxia Houpo Tang ineffective?” I explained, “Banxia Houpo Tang is used for phlegm accumulation causing throat obstruction, while Linggui Zhugan Tang is for throat obstruction due to water Qi rushing upward. The characteristics of the wiry pulse and moist tongue coating were indicative of the latter, and mistaking it for phlegm led to the saying ‘a difference of a hair leads to a difference of a thousand miles.’ The student nodded in agreement.

[In regards to] “a deep and tight pulse.” The depth signifies the interior, also representing water diseases, while the tightness indicates cold. Deep tightness precisely reflects the condition of a water-cold pathology.